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Paedodontic general anaesthesia and
compliance with follow-up visits at a tertiary
oral and dental hospital, South Africa
SADJ June 2013, Vol 68 no 5 p206 - p212
Y Kolisa,1 OA Ayo-Yusuf,2 DC Makobe3
Abstract
Objectives: The study aimed to describe the demographic
profile of children receiving dental general anaesthesia (DGA)
at the Pretoria Oral-and-Dental Hospital, South Africa,the
type of treatment received and the level of compliance with
the six-month preventive follow-up visit.
Methods: Retrospective review of records of children treated
under DGA between January 2009 and December 2010.
Results: The study group contained 78-children. Of these,
79.5% were between one and four years of age (mean
3.7-years; SD: 2.01), and 54% were female. The parents of
more than half the sample (56.4%) were unemployed. The
majority (55.2%) recorded no medical condition prior to undergoing DGA. Of the treatments performed, 63% were extractions (mean = 4.7 teeth/child), 51% involved placement
of composite restorations (mean = 3.4 teeth) and 18% were
fitting of stainless steel crowns (mean = 2.1 teeth). No preventive treatment was performed under DGA. Only 14 children (18%) returned within 15-months for follow-ups. Seven
returnees were re-booked for a second DGA appointment
for severely carious teeth; the rest received preventive treatment. Female children (Odds Ratio (OR): 0.28; p = 0.04)
and children with no medical-condition (OR: 0.20; p = 0.03)
were less likely to return for a follow-up visit. Children with
employed parents were more likely (OR: 3.50; p = 0.09) to
return for follow-ups.
Conclusion: This study highlights the importance of preventive treatment prior to and during DGA, especially in a setting
where the caries disease burden and unemployment are high.
Key words: children, dental treatment, compliance, prevention, dental general anaesthesia, paedodontics
1. Y Kolisa: BDS, MPH, MDent. Senior Specialist: Dept. of Community
Dentistry, School of Dentistry, Faculty of Health Sciences, University
of Pretoria.
2. OA Ayo-Yusuf: BDS, MSc, MPH, DHSM, PhD. Associate Professor,
Dept. of Community Dentistry, School of Dentistry, Faculty of Health
Sciences, University of Pretoria.
3. DC Makobe: BDS, Dip.Odont (Paedo). Lecturer - Paedodontics:
Dept. of Odontology, School of Dentistry, Faculty of Health Sciences,
University of Pretoria.
Corresponding author
Y Kolisa:
Senior Specialist: Dept. of Community Dentistry, School of Dentistry, Faculty
of Health Sciences, University of Pretoria, Cell: 083 780 0907,
Tel: 012 319 2531, Fax: 086 560 1552, E-mail: [email protected]
ACRONYMS
DGA: Dental General Anaesthesia
ECC: Early Childhood Caries
OR: Odds Ratio
INTRODUCTION
Early childhood caries (ECC) is a public health problem in
South Africa,1 affecting the quality of life of both the child and
the caregiver. Vast input from already constrained public resources is required to manage the condition.
Dental general anaesthesia (DGA) is used predominantly
in the treatment of ECC.2 Comprehensive dental treatment
can be extensive and may be difficult to perform on children younger than the age of 12 years. For this age group,
DGA can be valuable and may be justified when providing
restorative treatment and extractions in very young children
or for those who are unable to cooperate or too afraid.3 An
anxious, fearful child with rampant caries can benefit when
comprehensive dental treatment is performed at one visit
under general anaesthesia (GA).4 Resorting to the use of
DGA has therefore been shown to facilitate the immediate
improvement of the oral health and oral health-related quality
of life of the child.3 A single visit for multiple treatment is also
convenient for parents, especially for those from peripheral
locations, avoiding repeated days off work and reducing
travel costs.It has been was estimated that where multiple
treatment is involved, up to six regular dental appointments
may be required to complete the planned attention.4
Most studies on comprehensive dental treatment on children under GA have been conducted in developed countries, with only a small number in developing countries such
as Taiwan5 and the Islands of Trinidad and Tobago.6 A few
studies have also been carried out in the Middle East.7, 8 A
paper regarding compliance of Saudi parents with followup preventive care after DGA showed failure in nearly 54%
of cases.9 Jamjoom et al7 also showed that of the children
treated under DGA mainly for the management of rampant
caries in Jeddah, Saudi Arabia, only 10% returned for recall
visits within one year.
A South African study which evaluated the self-reported
compliance with a preventive dental care programme of
families whose children had received dental attention under
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GA showed that the majority of parents (51%) reported that
there was no change in their child’s frequency of sugar consumption following the treatment. Inappropriate sugar habits
continued after DGA. About 63% of the children treated under DGA returned for the one-week follow-up, but only 22%
returned for the three-month follow-up appointment.10 An
additional study in the same region highlighted the possibility of re-treatment under DGA because of a lack of preventive measures, which resulted in repeated severe caries.11
Primary prevention is deemed an important and economically viable intervention in managing ECC.12 According to
Gussy et al19 the premise behind the prevention of ECC lies
under four tenets: reducing the causative agent (by tooth
brushing, xylitol teeth wipes, parental example in maintaining oral health); reducing the substrate (by diet modification);
increasing the resistance of teeth (by use of fluoride dentifrices) and a combination of any of these approaches.19
Social factors rather than health variables are most often responsible for poor compliance with follow-up appointments,
according to a study reported by Elliott Brown et al12 and
have a greater impact in predicting that subjects would miss
appointments. Unemployed parents were most likely to be
at risk for missing recall clinic appointments, independent of
health insurance.12
Despite overall financial viability, DGA itself can indeed be
very costly, considering the fees for theatre, a hospital daybed, nursing personnel, anaesthetists, dentists and the dental consumables and materials. Therefore, it is not unlikely that
even those who have some form of health insurance may
have to face co-payment to the medical facility to cover costs.
It is important that preventive treatment such as fissure sealant and fluoride treatment is emphasised to the families of
young patients to avoid the repeated need11 for costly comprehensive treatment, even when DGA is deemed advantageous because it allows for single-visit treatment.2
Most of the comprehensive dental treatment in patients under the age of 12 years is successfully performed in the
dental chair, using normal local anaesthesia and even conscious sedation. However, for a minority of children paedodontic treatment under GA is the only way essential
comprehensive dental treatment can be performed. Limited
information is currently available on the socio-demographic
characteristics of these children, including the treatment received and their compliance regarding follow-up visits.
AIMS
The aim of this retrospective analytic study was therefore
to determine the characteristics of paedodontic patients
treated under GA and the compliance regarding a recall visit
following DGA at the Pretoria Oral and Dental Hospital in
South Africa.
SAMPLE AND METHOD
Data was collected retrospectively from the hospital records
of paedodontic patients who had received their first dental
treatment under GA at the Pretoria Oral and Dental Hospital in Pretoria, South Africa, between January 2009 and
December 2010. The study excluded disabled patients and
children over the age of 12 years. Collation of the collected
data took place in September 2011, thereby providing adequate time for even the last patient treated by the end of
2010 to have returned for the routinely scheduled six-month
follow-up visit after the DGA.
The Pretoria Oral and Dental Hospital is an academic hospital that serves the catchment area within the central business district and adjacent suburbs in Pretoria. The protocol
for paedodontic treatment under GA at the Pretoria Oral
and Dental Hospital is the following: children are evaluated by dentists in the paediatric department, and during
this consultation, all relevant medical and dental history is
taken. Oral hygiene education on the prevention of ECC
including diet modification is delivered to both parent and
child. Those children who require extensive dental treatment (restorative and pain-relieving), and on whom attempts at behavioural management to enable treatment on
the dental chair under local anaesthesia have been unsuccessful, are booked for a GA appointment. Three DGA
sessions are scheduled every week for comprehensive
dental treatment, as determined by the financial and logistic constraints of the Pretoria Oral and Dental Hospital. A
total of 12 disabled and young patients are thus booked in
a normal month without disruptions (144 per year).
In the period under review, fewer child patients were actually
treated than the maximum number that could have been accommodated. This was mostly related to the fact that some
children did not show up for treatment due to illness or to the
parents’ or guardians’ inability to honour the appointment. Other reasons include the periodic non-availability of anaesthetists,
or the fact that a booked child was deemed not fit for anaesthesia on the booked appointment day because of acute infection.
Consequently, the records of only 80 DGA children seen during the study period were reviewed and analysed.
The following information was retrieved from the records:
• Parents: employment status, marital status, age;
• Patient:
-- age at time of the first assessment visit prior to GA;
-- gender, ethnicity, area of residence which was recorded as ‘suburb’* or ‘township’*;
-- medical history;
-- date of first assessment visit;
-- date of first GA appointment;
-- treatment done under GA (categorised as extraction,
restoration, stainless steel crown, pulpotomy);
-- date returned for first follow-up visit after GA treatment;
and
-- treatment performed at the first follow-up visit.
*A township is defined as an often underdeveloped urban area of low
socio-economic status and a suburb is defined as an area where
reside people of middle to high income class.
Statistical analysis
SPSS Statistics Version 19 was used for the statistical
analysis. Bivariate Chi-square and t-tests were carried
out to determine group differences. Analysis of variance
(ANOVA) was applied where applicable, assuming nonequal variance post hoc tests. Multiple variable-adjusted
logistic regression was performed to analyse the factors
most likely to independently influence the degree of compliance regarding follow-up visits within the acceptable
time of about eight months. All t-tests were two-tailed and
the level of significance was set at p< 0.05, except where
specified at 10%.
RESULTS
The mean waiting time from the date of the first assessment
to the date of the DGA was 4.98 months (SD= 5.32).
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Table 1: Treatment performed under DGA
Treatment under GA
Mean number of treatments by age group
(SD)
No. of
patients
receiving
specified
treatment
Percentage of
total number
of patients
receiving
treatment
(n = 78)
Range
of the number
of treatments
delivered
p-values
when
comparing
the number
of treatments
between age
groups
1-4 years
N=62
5-8 years
N=12
9-11 years
N=4
Extractions
3.2 (3.6)
1.5 (1.9)
4 (1.8)
49
62.8
1-18
#0.06a
0.16b
0.81c
Composite fillings
1.6 (2.0)
3.1 (2.5)
1.3 (2.5)
40
51.3
1-8
0.18a
0.99b
0.54c
Glass ionomer fillings
1.7(2.0)
0.1 (0.3)
2 (4.0)
36
46.2
1-8
0.00a
0.99b
0.73c
Amalgam fillings
1.0 (1.6)
0.3 (0.9)
0 (0.0)
24
30.8
1-6
#0.07a
0.00b
0.69c
Pulpotomies
1.3 (1.7)
1.2 (1.7)
0.3 (0.5)
39
50.0
1-6
0.99a
0.03b
0.30c
Stainless steel crowns
0.3 (0.7)
1.1 (2.2)
0 (0.0)
14
17.9
1-7
0.52a
0.00b
0.29c
No scale and polish procedure and no fissure sealants performed
#Significant at the 10% level
a = Differences between 1-4 years and 5-8 years.
b = Differences between 1-4 years and 9-12 years
c = Differences between 5-8 years and 9-12 years
Of the 80 patients’ records, two were excluded from the
analysis as they were of patients above the age of 12 years.
Of the study participants, 79.5 %( n= 62) were four years
or younger. The mean age of the children was 3.67 years
(SD=2.01). The males in the study were on average significantly
younger than the females (3.36 years vs. 3.93 years; p<0.05).
Of the children treated, 53.8% (n=42) were female and 50%
were white, 25.5% were black and the rest, either coloureds
or Asians. Of all the paedodontic patients, 56.4% were from
the suburban areas. The mean age of the parents was 34.10
years with a median of 32 years, and 39.7% were single parents. More than half (56.4%) were unemployed.
Just over half (55.2%) of the children did not have a medical condition prior to DGA, but 13 (16.7%) had respiratory
problems, ranging from asthma, sinus problems to influenza
at the time of GA. A few of the children had other medical
conditions, such as jaundice (n=4), allergies, epilepsy and
hearing problems and some needed cortisone treatment
(n=3 for each condition). Further medical conditions were
bleeding tendencies (n=2), heart valve disease (n=1), hydrocephalus (n=1), HIV (n=1) and TB (n=1).
Treatment performed during DGA
Children received more than one type of treatment under
DGA. The preponderance of the treatment performed was
extractions, most being undertaken on children between
the ages of one and four years. The next most frequent type
of treatment was composite and glass ionomer restorations.
The least common was the placement of a stainless steel
crown (Table 1). There were significant mean differences
between age groups in terms of the treatments performed
under DGA (p<0.05). No primary preventive treatment was
performed under DGA. There was a positive correlation
between pulpotomies performed and the amalgam fillings
placed (r=0.45; p<0.00).
Compliance with follow-up visit and treatment
performed
The compliance by all the patients with the six-month follow-up visit was very poor: only 14 (18%) ever returned for
a follow-up visit (nine children returned between one and
seven months after the DGA and four children returned between eight and 15 months). Bivariate analysis revealed an
association between a number of factors and compliance
with follow-up within 15 months (Table 2).
Of the 14 children who returned for a consultation visit within
15 months of their DGA treatment, seven required a second
DGA appointment, because additional extensive treatment
was again required despite their having been successfully
treated under the initial DGA. All returning children received
more than one type of preventive treatment, including those
re-booked for GA (Table 3).
Predictors of compliance with the follow-up visit
A subsequent logistic regression analysis that controlled
for potential confounders revealed independent relationships between compliance with the follow-up visit within 15
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Table 2: Factors possibly associated with patients’ compliance with follow-up visit after dental treatment under GA
Compliance #
Compliant
(returned within 15 months)
Mean original waiting time in months
Non-compliant (never returned)
Mean
SD
Mean
SD
3.6
4.62
5.5
5.12
P-Value
0.542
Mean child age in years
3.9
3.18
3.6
1.69
0.004
Mean parent age in years
34.8
13.08
34.0
11.39
0.859
0.154
2.14
2.82
3.2
3.58
Count
%
Count
%
Male
10
71.4%
26
41.3%
Female
4
28.6%
37
58.7%
Suburb
8
57.1%
35
55.6%
Township
6
42.9%
28
44.4%
Has a medical condition
10
71.4%
25
39.7%
No medical condition
4
28.6%
38
60.3%
Parent:
Marital status#
Single
6
75.0%
25
80.6%
Married
2
25.0%
6
19.4%
Parent:
Employment status
Unemployed
5
35.7%
38
60.3%
Employed
9
64.3%
25
39.7%
African black
6
42.9%
14
23.0%
*Others
8
57.1%
47
77.2%
Mean number of extractions per child
Child: Gender
Residence
Child:
Medical history
Race#
0.04
0.58
0.03
0.53
0.08
0.12
P= 5% sig. level *White, Asian, Coloured
# Totals do not equal initial sample size because not all participants responded to the questions and one file was disqualified due to the paucity of
demographic information supplied
months and the following factors: gender, medical history
and the employment status of the child’s parents. Specifically, children who were female (OR: 0.28; CI= [0.06, 1.27])
and had no medical condition (OR: 0.20; CI= [0.05, 0.96])
were less likely to return for follow-up treatment (p<0.05).
Children with employed parents were more likely (OR: 3.50;
CI= [0.81 – 15.1]) to return for a follow-up visit within 15
months (p=0.09) (Table 4).
DISCUSSION
The aim of this study was to describe the characteristics
of paedodontic patients and their compliance with followup visits after dental treatment under scheduled DGA at
the academic hospital in the South African capital. The
service chiefly provided comprehensive dental treatment
in a single visit to uncooperative children, mostly four years
and below, for severe early childhood caries. The findings
are consistent with prior studies in Saudi Arabia7 and the
United Kingdom.4
nevertheless, it was consistent with the usual long waiting
times for appointments in public health facilities. Limited resources in terms of operating theatres, human resources and
an increase in the demand for services may be factors associated with such delays.14 Chaollaí et al1 reported maximum
waiting times for children awaiting DGA appointments of up
to 21 months in an audit in Yorkshire and the Humber Public
Health Authority in Leeds in the United Kingdom.15 The waiting times in the current study were not associated with the
patients’ medical history, which is in contrast to the findings
in another study, where co-morbidity was significantly associated with the treatment target date, within three months.16
The finding that the majority of the patients belong to the
white race group may be related to the fact that the study
site is located within the area where the catchment population is mostly local suburban communities historically known
to be populated by people classified as white.
The majority of the children in the study had teeth extracted,
rather than restored, and the mean number of teeth extracted was more than that observed in similar studies in Saudi
Arabia studies.2,7,8 It would thus appear that younger children
(four years or below), in this study had more advanced untreated caries. This trend, reported locally,11 of extractions
being more frequent than restorations, is a matter of concern
within the region, as it may indicate that children present
late for pain relief and sepsis treatment.17 The current study
noted that restorations with greater longevity such as stainless steel crowns were the least performed, in favour of the
resin restorations. Stainless steel crowns are more likely to
be longer-lasting and successful than composite and amalgam restorations in DGA.4,7,18 The most likely reason for the
predilection for composite treatment is that possibly anterior
teeth were mostly involved, because ECC invariably affects
anterior teeth.19
The waiting time of 4.98 months on average for a DGA appointment could be considered too long for a child in pain;
Consistent with the other studies reviewed,7,8-10 compliance
regarding preventive recall visits in this study was found to
The mean age in this cohort of patients was lower than that
reported in previous studies.2,4,7,8,10 This younger age probably reflects the differences in disease pattern and the high
burden of severe ECC in South Africa1 and the fact that
most of this caries is untreated.13
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Table 3: Treatment performed during a follow-up visit within 15
months
Treatment during the follow-up visit No. of patients n= 14 %*
Evaluation and booked for second
GA and medicated
7
50
Oral hygiene education and parent
motivation (OHI)
8
57.1
Scale and/or polishing
9
64.2
Fluoride treatment
4
28.6
NB*: % does not add up to 100% as a child could receive multiple
treatment procedures.
Table 4: Final logistic regression model of correlates of
compliance to follow-up visit
Gender
Male
Female
Medical
history
Yes
Parents
Employed?
No
No
Yes
OR (95% CI)
P-value
0.28 (0.06-1.27)
0.04
0.20 (0.05-0.96)
0.03
3.50(0.81-15.1)
0.09
be poor, with only about one out of every five children
treated returning within 15 months. The significant predictors for compliance regarding follow-up were related to
a child’s gender and medical status: children who were
male and who had a medical condition were found to be
more likely to return for a scheduled visit, even though
the DGA waiting time was not associated with medical
history. An existing medical condition may mean that the
child could be on some form of paediatric medication
which may affect the child’s dental health,20 which in turn
might require more regular treatment. This may explain
why children with no medical condition were less likely to
return for follow-up visit, possibly because they had no
oral disease symptoms.
Another probable predictor for compliance was the employment status of parents. Children with unemployed parents
tended to be more likely to not return for a follow-up visit.
The region is characterised by a high unemployment rate,
which would be linked to reduced affordability and thus
limited access to the facility because of costs relating to
transport. Although the facility is mostly used by the local
community, it is a referral hospital. According to the South
African government’s policy, treatment is free for children
under the age of six years,21 but there could have been
barriers to accessibility in the form of distance and transport costs. Unemployment is a predictor for accessibility,12
which therefore suggests a lack of funds for transport for
returning to the facility. It is therefore important to enlist
social support systems to encourage follow-up preventive
care – this has the potential for improving the likelihood of
honouring dental appointments even when a child experiences no symptoms.12
Half of the patients that returned for the follow-up visit presented with advanced dental disease again, requiring a second DGA appointment. This deterioration could be the result
of the persistent poor oral hygiene control, for example, no
change in the children’s poor dietary habits following DGA.10
The readiness to facilitate change seemed to be an impor-
tant predictor of whether parents adopted and maintained
preventive behaviours to improve their child’s oral health.22
A lack of knowledge also may contribute to any non –compliance of parents regarding the follow-up visit.22 This is an
indication that education and the motivation of parents is important, and that prior to the DGA appointment or treatment,
it is vital to emphasise the necessity of preventive treatment
to reduce the likelihood of the development of new disease.10
Parent motivation and education prior to DGA may therefore
improve overall compliance.
Study limitations
Given the small proportion of children who returned for a follow-up visit, caution should be exercised in drawing conclusions on the reasons for compliance. However, poor compliance following DGA is a trend that has been described in
numerous studies.2,7-10 It may be argued that this behaviour
could render conventional preventative clinic-based methods (which depend on regular dental attendance) less likely
to work in children with ECC. Alternative approaches which
are not facility-based could complement or supplement
these efforts.
The study design relied on a record review, which is not immune from reporting bias. However, precautions were taken
in that the recorder followed up on the correctness of the
data that was collated.
CONCLUSIONS AND RECOMMENDATIONS
It is apparent that there is a need for effective oral health
promotion within the facility targeted firstly at the parents of
children prior to the DGA, and secondly at the community in
the region in general. This study highlights the importance
of motivation and preventive treatment prior to, during and
after DGA, especially in a setting where unemployment and
the disease burden is high. It is recommended that more
emphasis is placed on the prevention approaches as highlighted by Gussy et al,19 which relates to the use of fluoride,
diet modification, removal of plaque and microbes by tooth
brushing and the chewing of xylitol gum. Although the services at the academic hospital are free for children under six
years, there may still be accessibility challenges which may
require general social support. Further investigations are
required to identify an intervention approach that improves
follow-up compliance; for studies to measure the effectiveness of compliance regarding preventive visits; to assess
the combination of both conventional facility-based preventive services and alternative supplementary preventive
methods for patients with ECC, and to examine any changing patterns in the use of DGA in the Pretoria Oral and Dental
Hospital. Given the current prevalence and severity of caries
in South Africa, DGA services might remain a real necessity
for a few vulnerable children.
Acknowledgement
The authors would like to express their appreciation to the Pretoria Oral and Dental Hospital and particularly the Departments of
Community Dentistry and Odontology for allowing and facilitating
the research.
Declaration: No conflict of interest declared.
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